Planning to stay in your own home as you get older? Medicare rules can be confusing. This guide will help you understand the basics so you can plan better.
What is Medicare?
Medicare is federal health insurance for people age 65 and older and for some people under 65 with certain disabilities or conditions.
The Four Parts of Medicare
Medicare has four parts. Each part covers different things. Each year during Medicare Open Enrollment, people can review and change their Medicare Advantage and Part D plans. Some people also change supplemental coverage.
Part A: Hospital Insurance
Part A helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care. You may still have deductibles, copays, or other out-of-pocket costs. What this means for you:
- When you go to the hospital and stay overnight
- Short stays in a nursing facility after being in the hospital (more on this below)
- Hospice care is for those who are very sick and are terminally ill
- Some short-term care at home after leaving the hospital
To qualify for skilled nursing facility care, you must have spent at least three consecutive hospital inpatient midnights within 30 days of admission to the facility. Just being kept in the hospital for monitoring (“observation status,” not an official hospital admission) does not count.
Part B: Medical Insurance
Part B helps cover:
- Doctor visits
- Lab tests and X-rays
- Shots like flu vaccines
- Durable medical equipment (like wheelchairs or walkers) when prescribed by a doctor and obtained from approved suppliers
- Outpatient physical therapy or occupational therapy, when medically necessary
Part C: Medicare Advantage
Medicare Advantage bundles your Part A and Part B coverage, and most plans also include Part D prescription drug coverage. These are private insurance plans approved by Medicare. What this means for you:
- Everything from Part A and Part B is included in one plan
- Most plans also include prescription drug coverage (Part D), but not all plans do
- Plans may offer extra benefits that Original Medicare does not cover, such as vision, hearing, and dental services. These benefits vary by plan
- You usually have to use doctors and hospitals within the plan’s network
Part D: Prescription Drug Coverage
Part D helps pay for medications. Plans cover a variety of brand-name and generic prescription drugs. Each plan has a list of covered drugs, called a “formulary,” that can vary in cost and specific drugs covered. What this means for you:
- Helps pay for medicines you take
- Each plan covers different medicines
- You need to check if your medicines are covered by the plan
The Difference Between Skilled Care and Custodial Care
Skilled Care
Medical care provided by licensed nurses or therapists. Some examples are:
- Changing surgical bandages
- Giving IV medications
- Physical therapy to help you regain mobility after a stroke
- Speech therapy after a stroke
Medicare pays for skilled care when it is medically necessary and aimed at improving a condition, typically for a limited period.
Custodial Care
Help with daily activities of living (ADLs) that do not require medical training. Some examples are:
- Help with bathing
- Help getting dressed
- Help eating
- Supervision for safety to reduce the risk of falls
Medicare does not pay for custodial care.
What Medicare Does Cover
Let’s be clear about what Medicare pays for, here are some examples are:
- Hospital Stays – Medicare Part A helps cover inpatient hospital care when you are sick and need to be admitted. You may still have deductibles, copays, or other costs.
- Doctor Visits and Tests – Medicare Part B helps cover doctor visits, lab tests, X-rays, and other medically necessary outpatient services.
- Short-Term Skilled Nursing Care – Medicare covers short-term care in a skilled nursing facility after a qualifying hospital stay, including nursing care, medications, wound care, and rehabilitation.
- Short-Term Home Health Care – Medicare covers limited home health services if you are homebound and need skilled care after an illness or hospital stay. This includes visits from a nurse or therapist for a short period. These services are usually part-time and not full-day care.
- Hospice Care – Medicare covers most hospice care for people with a terminal illness.
Here’s how short-term care works:
- Days 1–20: Medicare pays 100% of covered skilled nursing facility services per benefit period.
- Days 21–100: You pay a daily coinsurance while you continue to meet medical necessity requirements.
- After day 100: Medicare coverage for skilled nursing facility care ends for that benefit period.
Coverage can last up to 100 days per benefit period if you continue to meet medical necessity requirements, but it may end sooner if you no longer need daily skilled care. Medicare does not cover long-term custodial nursing home care or ongoing help with daily living activities.
What Medicare Does Not Cover
Medicare Does Not Pay for Custodial Care
Most long-term care helps with basic personal tasks of everyday life, sometimes called “activities of daily living.” Custodial care can include:
- Help with personal care (like bathing, dressing, and using the bathroom)
- Help getting in and out of bed
- Help with eating meals
- Supervision for safety
- Help with laundry and housework
- Rides to medical appointments (except ambulance)
This is a common mistake: Many people think Medicare will pay for someone to come help them at home every day with bathing, dressing, and meals. Without other coverage like Medicaid or long-term care insurance, you are usually responsible for these costs yourself.
Medicare Does Not Pay for Most Nursing Home Stays
Most nursing home care is custodial care, which helps with activities of daily living (like bathing, dressing, and eating). Medicare and Medigap generally do not pay for long-term custodial care in a nursing home or at home. Medicare only covers short-term nursing home care (skilled nursing facility care):
- After a qualifying hospital stay (generally 3 consecutive inpatient midnights)
- Only if you need daily skilled nursing care or rehabilitation services
- For up to 100 days per benefit period, if you continue to meet medical necessity requirements
- Not if you only need help with daily living activities
Medicare Does Not Pay for Dental, Vision, or Hearing Devices
- Most routine dental care
- Routine eye exams for glasses
- Hearing aids
- Dentures
There are some exceptions, such as cataract surgery (and related corrective lenses), glaucoma screening for eligible individuals, and medically necessary dental care tied to another covered medical procedure. Coverage depends on medical necessity and specific clinical criteria, so it is important to check what is covered in each situation.
Examples of Medicare Covered Versus Not Covered
Mr. Johnson had a stroke. In the hospital, he received skilled care from nurses, doctors, and therapists. After he went home, Medicare may cover home health services such as physical therapy when he meets eligibility requirements. This is considered skilled care.
But Mr. Johnson also needs help getting dressed every morning, help bathing, and supervision to ensure safety and medication adherence. This is custodial care. Medicare does not cover this type of ongoing daily assistance, so families typically need to pay for it themselves or use other support programs.
What Can You Do When Medicare Doesn’t Cover What You Need?
If you need daily help at home or long-term care, here are your options:
- Pay Out of Pocket – Use savings, retirement funds, or other assets to pay for care.
- Long-Term Care Insurance – If purchased before care is needed, it may help cover daily care at home or in a facility, depending on the policy.
- Medicaid – A joint federal and state program that provides health coverage for eligible low-income individuals. Medicaid can cover long-term care, including nursing home care and some home- and community-based services, depending on state rules.
- Veterans Benefits – Eligible veterans may qualify for long-term care support through the Department of Veterans Affairs, depending on service history and care needs.
- Community Programs – Local programs can help support independence at home, such as Meals on Wheels, transportation services, senior centers, and adult day programs. Contact your local Area Agency on Aging to learn what is available.
Important Questions to Ask
When you are in the hospital or going to rehab, ask these questions:
- “What happens when the Medicare coverage ends?”
Make a plan ahead of time so you know what options are available next. - “Am I being admitted to the hospital or am I under observation?”
Remember, you generally need at least 3 consecutive inpatient midnights to qualify for Medicare-covered skilled nursing facility care later. - “What kind of care will I need — skilled or custodial?”
This helps determine whether Medicare will cover the care or whether you may need to pay out of pocket or use other support. - “How long will Medicare cover this?”
So you understand how long coverage may last and what conditions could end it.
Tips
- Keep Good Record – Save all hospital paperwork, write down dates of hospital stay, keep track of what Medicare pays, and what you pay
- Talk to a Social Worker, discharge planners, or case manager – Most hospitals and nursing homes have staff who can help you understand your options and find resources.
- Plan Ahead – Don’t wait until Medicare stops paying to figure out what to do next. Start planning early.
- Ask Questions – If you don’t understand something, keep asking until you do. It’s okay to ask the same question to different people.
Get Help
You don’t have to figure this out alone. Contact:
- Your local Area Agency on Aging
- Medicare’s helpline: 1-800-MEDICARE (1-800-633-4227)
- A social worker or patient advocate at the hospital or nursing facility
This guide gives general information about Medicare. It is not legal or financial advice. Medicare rules can be complicated and may change.